<p> MINNESOTA PETROLEUM TANK RELEASE COMPENSATION BOARD MULTIPARTY CHECK REQUEST</p><p>LEAK # ______</p><p>BACKGROUND INFORMATION</p><p>PLEASE PRINT CLEARLY OR TYPE Applicant’s Name Corrective Action Site Name (if a business)</p><p>Street Address Corrective Action Site Address</p><p>City, State, Zip Code City, State, Zip Code</p><p>Petrofund Applicant’s Telephone Number Contact Person and Telephone Number at Site</p><p>( ) ( )</p><p>Applicant is:</p><p>______Owner ______Operator ______Other (please specify):</p><p>First Additional Party’s Name Second Additional Party’s Name</p><p>Street Address Street Address</p><p>City, State, Zip Code City, State, Zip Code</p><p>First Additional Party’s Telephone Number Second Additional Party’s Telephone Number</p><p>( ) ( )</p><p>First Additional Party’s Status Second Additional Party’s Status</p><p>_____ Advanced Funds For Corrective Action _____ Advanced Funds For Corrective Action</p><p>_____ Provided Corrective Action Services ____ Provided Corrective Action Services Dollar Amount Dollar Amount</p><p>$______$______CERTIFICATION</p><p>I am the applicant for reimbursement and hereby request that the Minnesota Petroleum Tank Release Compensation Board issue a multiparty check that includes each party listed on the previous page(s). </p><p>Each listed party either advanced funds to pay the costs of the corrective action or provided corrective action services at the specified corrective action site.</p><p>I understand that this multiparty check request is limited to the application that I signed and dated , 201 _, and that it relates only to payment that may be made from the Petroleum Tank Release Cleanup Fund as a result of that specific application.</p><p>I also understand that the Board will make payment to me and the listed party or parties by a multiparty check payable jointly to me and the listed party or parties and requiring endorsement by all payees. I further understand that this payment does not constitute the assignment of my right to reimbursement to any consultant, contractor, or lender.</p><p>NOTARIZATION Signature______Subscribed and sworn to before me this_____day</p><p>Name (print/type)______of______, 201______.</p><p>Title______Notary Public______</p><p>Date Signed______[Stamp]</p><p>My commission expires______</p><p>[7/2011]</p>